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General NPI Number Information
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NPI Number | 1265412605
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Entity Type | Individual
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Provider Name | DARRELL JACK POTTER M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/20/2006
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Last Update Date | 11/03/2019
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Provider Practice Location Address
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Address Line | 5491 W ROSEBUD CT SE #4
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City | KENTWOOD
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State | MI
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Zip | 49512-9464
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Country | US
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Telephone | 334-322-3489
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Fax |
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Provider Business Mailing Address
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Address Line | 6214 SWEET CLOVER LN SE
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City | CALEDONIA
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State | MI
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Zip | 49316-8291
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Country | US
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Telephone | 334-322-3489
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 2006-01651
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | MD-42830
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License Number State | IA
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Taxonomy #3
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 2016005465
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 4301030727
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License Number State | MI
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